599 - POwer Up to PO: Boosting Transitions from IV to PO of Gastric Acid Suppressive Medication in Patients admitted to Pediatric Hospital Medicine

Publication Number: 2584.599

Madeline Parr, Cohen Children's Medical Center, Hackensack, NJ, United States; Ruchi Tejwani, Cohen Children's Medical Center, Demarest, NJ, United States; Natasha D. Dombrowski, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island City, NY, United States; Anna Bambaci, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Whitehouse Sta., NJ, United States; Matthew Oswald, Cohen Children's Medical Center, New Hyde Park, NY, United States; Nancy Palumbo, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Brooklyn, NY, United States; Aidan Doona, Cohen Children's Medical Center, Garden City, NY, United States; Anupama Subramony, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, United States; Diana Gluskin, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Wantagh, NY, United States

Background: Hospitalized children requiring gastric acid suppression are commonly treated with intravenous (IV) medications despite the availability of equally effective oral (PO) formulations. IV formulations carry drawbacks of higher cost, increased pain and anxiety with IV placement, and severe risks of extravasation, thrombophlebitis, and catheter-associated bloodstream infections, presenting an opportunity to improve patient care and resource stewardship.

Objective: This quality improvement initiative aims to decrease the amount of unnecessary time spent on IV gastric acid suppression by 20% among pediatric hospital medicine patients within six months.

Design/Methods: Leveraging plan, do, study, act (PDSA) methodology, we identified key drivers, engaged key stakeholders, elicited buy-in from resident and attending physicians, and created a multidisciplinary pharmacy and physician team. Interventions included a daily, in-person pre-rounding checklist between pharmacists and senior residents, educational sessions for house staff and hospitalists, and signage to prompt IV to PO transitions. The primary outcome measure was time in hours on an IV gastric acid suppression formulation that could have been PO. NPO time was subtracted from eligible patients. Exclusion criteria included children < 2 months of age, gastrointestinal bleeds, persistent vomiting or diarrhea resulting in an NPO order, malabsorption syndrome, or severe immunocompromise. The process measure was the number of pharmacist-senior resident interactions that prompted transitions. Balancing measures were 1) the rate of failed transitions and 2) overall trends in total IV and PO gastric acid suppression usage. Data was analyzed using statistical process control charts.

Results: Six weeks after implementation, a centerline shift was observed with time on IV gastric acid suppression when PO was feasible, decreasing by 61% from an average of 31.7 hours to 12.4 hours (Figure 1). This centerline shift has been sustained for six months to date with decreased variation supporting a non-random result. Our balancing measure showed no change in the rate of failed transitions.

Conclusion(s): Implementation of a pre-rounding pharmacy checklist, comprehensive education, and visual reminders decreased the time a patient was unnecessarily maintained on IV gastric acid suppression by 61% with a centerline shift within 6 weeks of implementation, surpassing our goal of 20%. Long-term evaluation is ongoing to determine if this change is sustained.

XBar Chart Illustrating Outcome Measure over Time
XBar chart where each point indicates the mean number of hours per week that patients were on IV gastric acid suppression which could have been a PO formulation. The first intervention was a pharmacist checklist performed daily before rounds to the PHM teams with suggestions of IV to PO transitions of gastric acid suppression (dotted arrow), the second intervention was resident and attending education along with visual reminder cards attached to desktop and mobile computers (gray arrow), and the third intervention was repeat education and refreshment of visual reminders (solid black arrow).